School Mental Health Perspectives from Baltimore and Beyond

1. School Mental Health Perspectives from Baltimore and Beyond Mark D. Weist Center for School Mental Health Analysis and Action, University of Maryland October, 2005

2. Outline • The Baltimore Experience • Needs of Youth and Reasons for School Mental Health • A Public Mental Health Promotion Approach • Empowering Educators • An Emerging Advocacy Agenda

3. Baltimore • A city of around 600,000 growing again • Significant sociodemographic challenges • Collaborative relations between committed child system leaders • Vigorous non-acceptance of Same Old Same Old • History in school health • Funding experience and perseverance • Interdisciplinary networks • Political will and activism

4. School Mental Health Program • Established in 1989 in 4 schools • Currently operating in 30 schools • Annual budget of around $1.1 million ($800,000 contracts; $300,000 fee-for-service) • Interdisciplinary group of about 30 staff

5. SMHP – 10 Program Qualities • We build from the access advantage • We strive to be viewed as from the school • Families, youth and other stakeholders guide the program • A proactive, energetic approach is taken • A full range of services is provided

6. 10 Program Qualities (cont.) • Continuous quality improvement is emphasized • We help to build school-community partnerships • We’re careful about diagnoses, and focus on strengths and environmental interventions • We are truly interdisciplinary • We strive for services to be developmentally and culturally relevant and based on evidence of positive impact

7. Center for School Mental Health Analysis and Action

8. CSMHA • Established in 1995 with a grant from the Health Resources and Services Administration (HRSA) • Renewed 5-year funding in 2000 from HRSA, with co-funding from the Substance Abuse and Mental Service Administration (SAMHSA) • Renewed 5-year funding in 2005 from HRSA and SAMHSA with a focus on policy analysis and dissemination

9. Needs of Youth and Reasons for School Mental Health

10. The Crisis of Youth Mental Health in the U.S. • About 20% of youth, ages 9 to 17 (15 million), have diagnosable mental health disorders, (and many more are at risk or could benefit from help) • Between 9-13% of youth, ages 9-17 years, meet the federal definition of serious emotional disturbance (SED)

11. The Crisis of Youth Mental Health in the U.S. (cont.) • Less than 30% of youth with diagnoses receive any services, and these services are often inadequate • For the small percentage of youth who do receive services, most actually receive them in schools

12. Growing Focus on School Mental Health (SMH) in the U.S. • U.S. Surgeon General Reports (1999, 2000) • President’s New Freedom Commission on Mental Health Report (2003) • Mandates of “No Child Left Behind” and Individuals with Disabilities Education Act (IDEA) • Progress in localities and states • Collaborative research-practice-training networks

13. President’s New Freedom Initiative • First presidential commission on mental health since 1978 • Widely disseminated document: Achieving the Promise: Transforming Mental Health Care in America (see www.mentalhealthcommission.gov) • 6 goals, 19 recommendations • Impact expected to last for “decades”

14. President’s New Freedom Commission (cont.) Goal 4: Early Mental Health Screening, Assessment and Referral to Services are Common Practice 4.1 Promote the mental health of young children 4.2 Improve and expand school mental health programs 4.3 Screen for co-occurring mental and substance abuse disorders and link with integrated treatment strategies 4.4 Screen for mental disorders across the lifespan and connect to treatment supports

15. In Addition to Enhanced Access, SMH can: • Reduce stigma for help seeking • Promote generalization/maintenance of intervention gains • Enhance capacity for prevention/MH promotion • Foster clinical efficiency and productivity • Promote a natural, ecologically grounded approach to helping youth and families

16. SMH Impacts • Based on a limited knowledge base, when done well SMH programs and services are associated with: • Strong satisfaction by diverse stakeholder groups • Improvement in student emotional/behavioral functioning • Improvement in school outcomes (e.g., climate, special education referrals, reduced bullying, fewer suspensions)

17. Expanded School Mental Health (ESMH): • Programs join families, schools, mental health and other community systems • To develop a full array of effective programs and services that improve the school environment, reduce barriers to learning, and provide prevention, early intervention and treatment • for youth in general and special education

18. Critical Challenges for the Field • ESMH still in a relatively small percentage of schools • Efforts remain marginalized and under-supported (STIGMA) • Interdisciplinary and intersystem turf and tension • Considerable variability in experience • Limited community ownership of the programs

19. A Central Challenge • School mental health is a tenuously supported field with efforts in most communities scattered at best • Scattered, unsupported services do not lead to the achievement of critical outcomes • We need to build support for effective services to enable the documentation of enhanced outcomes, which will in turn fuel advocacy efforts and bring needed resources into the field

20. A Time of Great Opportunity • Two plus decades of experience in ESMH • Growing federal awareness and support • Many communities showing strong leadership • Development of organized national and state networks • Increasing international discussion and attention (see www.intercamhs.org)

21. A Public Mental Health Promotion Approach

22. Factors Necessary to Achieve Desired Outcomes for Youth Through ESMH Programs and Services(Weist, Paternite & Adelsheim, 2005)

23. “Enhancing Quality in Expanded School Mental Health” • Three year, three state (Delaware, Maryland, Texas) study seeking to implement and evaluate a framework for systematic quality assessment and improvement in school mental health • Funded by the National Institute of Mental Health (2003-2006)

24. Principles for Best Practice in Expanded School Mental Health • 1) All youth and families are able to access appropriate care regardless of their ability to pay • 2) Programs are implemented to address needs and strengthen assets for students, families, schools, and communities • 3) Programs and services focus on reducing barriers to development and learning, are student and family friendly, and are based on evidence of positive impact

25. Principles (cont.) • 4) Students, families, teachers and other important groups are actively involved in the program's development, oversight, evaluation, and continuous improvement • 5) Quality assessment and improvement activities continually guide and provide feedback to the program • 6) A continuum of care is provided, including school-wide mental health promotion, early intervention, and treatment

26. Principles (cont.) • 7) Staff hold to high ethical standards, are committed to children, adolescents, and families, and display an energetic, flexible, responsive and proactive style in delivering services • 8) Staff are respectful of, and competently address developmental, cultural, and personal differences among students, families and staff

27. Principles (cont.) • 9) Staff build and maintain strong relationships with other mental health and health providers and educators in the school, and a theme of interdisciplinary collaboration characterizes all efforts • 10) Mental health programs in the school are coordinated with related programs in other community settings

28. Integrated Systems to Support the Development of All Children Systems of Prevention and Promotion All Students (universal) Systems of Early Intervention Students At-Risk (selected) Systems of Treatment Students with Problems (indicated) School, Family, and Community Partnerships From: Zins (in progress).

29. Importance of Family Partnerships • SEARCH Institute study: • As parental involvement in schools increased, problem behaviors in students (alcohol use, violence, antisocial problems) decreased • Roehlkepartain & Benson, 1994

30. Barriers to Family Partnerships • Service availability • Stigma • Fear of being blamed • Feeling unwelcome in the school • Fear of violated confidentiality • Perceived lack of mutuality

31. Traditional Approach • “In the past, families were seen primarily as contributing to the mental health problems of their children, and their ONLY ROLE was in treatment to alter their structure and/or functioning” (Osher, 2001)

32. Best Approach • “The model of therapist as expert is replaced by a shared-learner framework in which both parties (family member and clinician) contribute knowledge and insight” (Axelrod et al., 2003)

33. Key Processes in Working with Families • Engagement • Empowerment • Support • Collaboration

34. Engagement • In initial family contacts: • Clarify child’s need for services • Openly discuss attitudes and past experiences with the mental health system • Identify and strategize about probable obstacles • Identify concrete, practical issues that can be addressed immediately • Establish communications systems to promote continuity and stability in services (see McKay, Nudelman, & McCadam, 1996)

35. Empowerment • Reduce perceived barriers to successful outcomes • Develop realistic and optimistic goals for treatment • Provide or provide access to relevant information • Ensure collaborative decision making and parental choice • Encourage involvement in relevant organizations and in advocacy

36. Support • Connect families to needed resources • Together consider sources of support within the family, neighborhood and community, and at state and national levels • Be encouraging and optimistic in all interactions

37. Collaboration • Involve family members as equal partners in understanding problems and in developing and implementing interventions to address targeted problems • On an ongoing basis request feedback from families about how you are doing, how the program is doing, and how the community is doing in responding to the needs of children, asking for their recommendations

38. An Excellent Overview Article: Hoagwood, K.E. (2005). Family-based services in children’s mental health: A research review and synthesis. Journal of Child Psychology and Psychiatry, 46(7), 690-713.

39. Primary Secondary Tertiary Sch. Psy. XOXOXO XXXXXX XX Sch. SW. XOXOXO XXXXXX Sch. Co. XOX0 OOO Com. St. XO OOOOOO OOOOOO GEN.ED=O SPEC.ED=X Deciding on Roles in a School(no stereotyping intended)

40. The Optimal School Mental Health Continuum? • 10-20% Broad Environmental Improvement and Mental Health Promotion (CHANGE AGENT ROLE) • 50-60% Prevention and Early Intervention (PREVENTION SPECIALIST ROLE) • 20-30% Intensive Assessment and Treatment (THERAPIST ROLE)

41. Change Agent Activities • Promote positive relationships in the school • Participate on school planning teams • Assist in mapping and coordinating various programs and services • Assist in bringing resources into the school • Help to improve the environment

42. Strategies for Environmental Improvement • Assess the school climate; problem solve with peers and families and students on strategies for improvement • Use the Assets framework to promote staff-student engagement and positive relationships • Assist in ensuring school safety • Assist in bringing in resources (e.g., mentoring programs, community members as hall leaders)

43. Friendly, rewarding and supportive atmosphere Supports cooperation and active learning Forbids physical punishment and violence Does not tolerate bullying/harassment Values the development of creative activities Connects school and home life Promotes equal opportunities for participation WHO 2003: Psychosocial Environment (PSE) Profile

44. Prevention Specialist Activities • “Triage” mental health (1-3 sessions without diagnosis) • Working collaboratively with educators to improve classroom behavior • Building a theme of mental health skills as promoters of student learning • Implementing skill training groups

45. The Effective Therapist • Feels well trained, supervised and supported • Feels integrated into the school(s) • Is able to establish and maintain strong relationships with other staff and with students and families • Interacts with families and students as collaborators, building on their strengths • Is able to conduct an assessment in a way that is therapeutic

46. The Effective Therapist (cont.) • Is able to match delivered services to students and families in a way that optimally matches their presenting needs and goals • Develops and implements interventions from the science base • Works closely with a range of people important to the student

47. The Effective Therapist (cont.) • Is continually evaluating whether the current plan and services are effective, and is making adjustments when indicated • Understands and makes explicit differences in role functioning (e.g., as therapist vs. mentor) • Closes cases when problems are mostly resolved in a way that is collegial and allows for some ongoing contact

48. Three Critical Themes in Intervention • Reduce, help to buffer stress and risk • Enhance protective and resilience factors • Train in evidence-based skills

49. Addressable Stress/Risk Factors • Family Level • Abuse and neglect • Criminal behavior • Substance abuse • Family isolation • Overcrowding • Emotional/behavioral problems in family members • Morbidity and mortality in family members

50. Addressable Protective Factors • Family level • Support and nurturance • Rituals and routines • Self-control displayed and modeled by family members • Healthy behaviors by family members